| NPI | 1255161204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8768-023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-010872) |
| Enumeration Date | 2024-08-05 |
| Last Update Date | 2026-02-11 |